British Drug and Alcohol Policy: IV. The Controversy over Methadone

Although a number of drugs cause problems in the UK, the country is remarkable among developed nations in the extent to which heroin dominates as the primary illegal drug. The main treatment response to the heroin-addicted population in recent years has been to dramatically expand methadone maintenance.

According to Professor Susanne MacGregor’s new book on drugs in the UK, the number of drug users in treatment in the UK has grown from 67,000 in 1994 to about 200,000 in 2008, at a cost to the National Treatment Agency of Â£398 million pounds (This is NTA’s “ring-fenced” budget in 2007/08). Most of this treatment is methadone provided to heroin addicted individuals. The extensive use of methadone coupled with the closure of many residential rehabilitation programs that do not prescribe medications generated a firestorm of criticism against the Labour government. With the arrival of a new government, the critics have receptive ears into which to speak, and an overhaul has been promised.

The criticism of UK methadone maintenance has several strands which are important to untangle. One is that the care in UK methadone clinics is often of poor quality. Researcher David Best has documented that a patient who spends an entire year receiving methadone might get a few hours of counseling, total. Clinic time is devoted to providing, managing and recording the methadone dose and doing other paperwork, with almost no attention given to what should be a staple of drug treatment: Trained, concerned staff members taking a genuine interest in patients as individuals, finding out what is happening in their life and helping them tackle the problems they face. Another serious problem is the lack of careful monitoring for continued use of illegal drugs, which in some cases seems to reflect a mentality that a little less street heroin consumption is a good enough outcome because it might translate into less property crime. I have heard no one in the U.K. (on either side of the methadone debate) disagree with the proposition that methadone services in the UK have serious quality problems.

The second strand is more philosophical, and is reminiscent of the cultural battles that occurred in the U.S. in the late 1960s and 1970s over methadone vs. â€œdrug-freeâ€ treatment. A significant camp in the U.K. objects to methadone on principle, arguing that a methadone patient is still a drug user, and therefore has not achieved the desired outcome of substance-free living. Iain Duncan Smith, MP and the Centre for Social Justice (A centre-right think tank with influence and gravitas) are most associated with this viewpoint, which also resonates to a certain extent with the woman on the Clapham omnibus. Smith is now heading the Department of Work and Pensions and I am led to understand that his Cabinet Committee on Social Justice will make addiction a signature issue. One still hears fundamental philosophical objections to methadone in the U.S., but they have become less common as recovery organizations (e.g., 12-step fellowships) have enjoined their members from “playing doctor”, historical research has shown that AA founder Bill W. asked methadone pioneer Dr. Vincent Dole if he would invent a methadone for alcoholics, and well-known recovery advocates like Bill White have endorsed the principle of “many pathways to recovery”, explicitly including medication-assisted treatment (This is also the position of President Obama’s National Drug Control Strategy).

The third strand of methadone criticism in the UK is political. Some conservatives in the U.K. and the U.S. believe the expansion of methadone prescription without concurrent monitoring of drug use via urinalysis (or even, apparent concern about it) is a sign that “left-wing harm reduction extremists have captured the UK treatment field”. This raises the stakes in their eyes because this becomes not just about policies they don’t like, but about people they don’t like and want to battle politically. I have friends among these critics, but with respect I think they have misread the situation, for two reasons.

First, a long government career including being involved in managing a huge substance use disorder treatment system tells me that what likely happened in the UK was not some philosophical epiphany among methadone providers but a scramble to respond quickly to great pressure to expand the number of people in treatment. The easiest way to do that was to give everyone less service and build a lot more outlets (The same phenonemon has occurred in other areas, for example when Congress demanded a massive increase in the number of children enrolled in Head Start without specifying no detriment in quality). Maybe some people of a particular political persuasion like the end result, but in terms of how and why the system changed I think the best explanation is that a massive bureaucracy adapted clumsily to demands set upon it rather than a cabal of ideological insiders nimbly implemented their worldview. Second, to think of methadone as a leftist plot distorts UK political history. The suggestion to expand methadone and needle exchange in response to the AIDS epidemic came from the non-partisan Advisory Council on the Misuse of Drugs (ACMD; Dame Ruth Runciman was a key member) and the policy was implemented by a Tory’s Tory, PM Margaret Thatcher.

A few years ago the UK Drug Policy Commission and David Burrowes, MP kindly hosted a private briefing session for me with Tory backbenchers and other players, during which I explained how methadone was used in the U.S. and why I consider it a valuable part of the treatment system. We were under the Chatham House rule so I can’t go into details, but I can say that the extreme views expressed in the Daily Mail et al. (e.g., close all methadone services tomorrow) were nowhere in evidence. Indeed, it was as thoughtful and nuanced a discussion of drug policy as I have ever had with elected officials. This is in line with a general rule that press-mediated “drug policy debate” often makes everyone involved sound less reasonable and intelligent than they are (cf. the debate between Home Secretary Alan Johnson and ACMD head David Nutt, both of whom come across in person much better than they did in their recent tussle, which was fueled by high emotion and too sloppy by half press coverage). I left the briefing session with hope, which I still consider realistic, that if the Tories got into power they would take a “mend it not end it” approach to methadone maintenance services.

David Burrowes (who is now a PPS) has continued to be my man of the match on methadone issues for saying things such as the following quote, which comes from a Guardian story from which the photo above is cribbed: “It’s not for me to cast moral judgments about whether methadone is wrong or right…We need to look at outcomes, and the outcomes are just not good enough.”. To my way of thinking, this is really the only question at issue. I respect and like Professor Neil McKegenay, but I disagree with his proposal to limit the amount of time anyone can receive methadone (e.g., six months or a year or two, UPDATE: SEE NEIL’S COMMENT BELOW). If care is poor and/or the patient is doing badly, one day is too long. If care is good and/or the patient is doing well, one year may not be enough. I hope the new government will take this to heart and try to get the best outcomes it can from the potential life-saving treatment that methadone can be, which will entail changing the practice style of some clinics, shifting patients who continue to use drugs to other forms of treatment, and communicating a new set of expectations to all methadone providers (e.g., if you want public money for your program, test for illegal drugs and put contingencies in place for immediate response when use continues). If the end result is that fewer patients are in methadone treatment, but the treatment they receive is of higher quality, that should be a net gain for public health and public safety.

The methadone controversy ties into two other issues that are currently hot in the UK, namely what should count as “recovery” from addiction, and, what policy levers could make the treatment system produce it more often? These questions will be the subject of my next posts in this series.

One is that the care in UK methadone clinics is often of poor quality. Researcher David Best has documented that a patient who spends an entire year receiving methadone might get a few hours of counseling, total. Clinic time is devoted to providing, managing and recording the methadone dose and doing other paperwork, with almost no attention given to what should be a staple of drug treatment: Trained, concerned staff members taking a genuine interest in patients as individuals, finding out what is happening in their life and helping them tackle the problems they face.

While anyone should agree that treatment options ought not to be limited to the kind of interaction described above, wouldn't it also be a good thing if every narcotics addict in the country could easily get access to withdrawl-preventing drugs on demand, with minimal hassle of the kind that might deter him from doing that? Don't the Dutch have pretty good coverage of their addict population, and don't they find that there's some fraction of heroin users who don't want "concerned staff members taking a genuine interest" in their affairs? And isn't it true that such addicts have to either be pretty much left alone, since no one wants to institutionalize them involuntarily?

Actually, providing less services at more outlets might be a reasonable initial response to an emergency. The follow-on should probably not be that it's necessary to immediately start planning a route for everybody to eventually get off methadone, or even for everybody who gets methadone to be in some other kind of treatment too.

The experiment on limiting time under methadone maintenance has been done, and the results are disastrous. If "going off methadone involuntarily" were the name of a medicine, the FDA would pull it from the market overnight. On the other hand, I'm surprised that UK maintenance is still fixated on methadone; buprenorphine and LAAM both belong in the mix.

Actually when I raised the question of time limited methadone it was in terms of a two year period with the individual then moving on to a drug free programme. Clearly to simply end a prescription would not be desirable but as we have seen in the UK there is a real risk of individuals remaining on methadone without any clear sense on the part of the prescribing agency what progress the individual has made how near they are to being able to reduce their reliance on this medication and at what point they will be able to benefit from a drug free programme. My own view is that the situation in which we find ourselves where individuals can remain on methadone for extended period of time is only in part due to prescribers being of the view that opiate substitute medication is the equivalent to insulin or heart medication and rather more probably the result of drift and an inclination once treatment starts to continue to provide that treatment rather than critically assess whether the treatment can be reduced discontinued. I dont think that we should simply drop the idea of time limited methadone on the basis that where it has been tried in the past it has not worked because clearly there are a variety of ways in which time limiting could be implemented. Perhaps more critically however than a fixed time limit is a much clearer and contemporaneous assessment of what progress individuals are making on methadone such that where the medication is no longer associated with positive improvement then it would be possible to consider what other services might better enable the individual to progress further along the road to recovery.

Prof. McKeganey: Would you propose to do carefully controlled field trials before proceeding to implement a new policy? And have you thought through the ethical issues of doing the trials?

Untreated active street heroin addiction has an annual mortality of 2-3%. Most non-substitution therapies fail to attract or retain clients, and those who cease treatment are likely to go back to active use. Kimber et al. find that "For each additional year of opiate substitution treatment the hazard of death before long term cessation fell 13% (95% confidence interval 17% to 9%) after adjustment for HIV, sex, calendar period, age at first injection, and history of prison and overdose."

It's hard for me to see any intervention promising enough to justify forcing someone maintained on methadone to attempt abstinence, given the risks. Of course that doesn't mean we should be content with current practice. But "First, do no harm" ought to apply to ending therapies as well as starting them.

Mark it is interesting that you refer to the recent BMJ paper from Kimber and colleagues. You will have seen from that paper that those drug users who were prescribed methadone had a median length of injecting of twenty years compared to five years for those who were not prescribed methadone and the authors of this report state that methadone prescription was inversely related to cessation and thererfor recovery. the principle of not doing harm a applies equally to methadone as well as to its cessation where the drug is being prescribed without clear benefit to the individual concerned and where indeed the individual may have become dependent on the medication itself in a form of iatrogenic drug dependency. we know from research that the majority of dependent ug users approach services looking for help to become drug free and yet in the UK that is not what they are bein provided with. We Need to ensure that individual are not being parked on methadone and that services are able to support addicts on the road to recovery rather than the road of their continuing . I am not talking about forcing individuals down the road to recovery indeed such force is not necessary where drug users are seeking help to become drug free but i do feel there is a real risk in addiction services of prescribers themselves becoming dependent on the medication they are making available to individuals who have a demonstrable capacity to become drug dependent.

If good practice prevailed, Neil and Mark Kleiman would have no need to debate, as they would be reassured that patients had appropriate treatment in an appropriate setting after appropriate diagnosis and careplan. Sadly, that happens rarely and the oath of "first do no harm" is ignored. We must work together to show governments what best practice is, which usually results from working together around the client, free to make clinical decisions independent of the huge vested interests currently dominating treatment purchase.

Actually there is a larger problem than the issue of time limited methadone which Keith's excellent blog reveals which is contained in his note that in his many meetings and contacts he has "heard no one in the U.K. (on either side of the methadone debate) disagree with the proposition that methadone services in the UK have serious quality problems". In fact the criticisms of the UK methadone programme have largely come from individuals who are operating outside of that programme. What this means is that hardly any of the people working within methadone programmes in the UK at a senior level have commented openly about the poor quality service that methadone agencies are delivering. What we appear to have is a quiet acceptance of the poor quality service provision that has become commonplace. This is either because our services lack sufficient care for their clients or because we have created a climate where those who know best about the quality of the service they are delivering have lacked the courage to speak out about those shortcomings. In doing so they have in their own way contributed to the proliferation of poor quality service delivery. There are highly paid and influential voices within the UK that have shaped our drug treatment world and those voices have been largely silent on the state of affairs that has arisen over the last ten or so years. We can critiicise government for funding treatment on the basis of a presumed reduction in criminality but it is those working and shaping the drug treatment industry that are ultimately responsible for the shortcomings in the treatment system that it has taken outsiders, including the media, to draw attention to. Many of those same individuals will be seeking to advise the new government about developments in drug treatment services and it is to be hoped that his time round their new found concern for recovery leads them to shape drug treatment services about which it cannot be said in due course that nobody was unaware of the serious deficiencies in the quality of the services provided.

Patients in the UK participating in methadone treatment have for years been complaining of the chronic low doses only being permitted by prescribing clinics. This lies at the heart of the failure of the UK system to stem illicit drug usage among this population. Success comes from putting to rest the compulsion to use illicitly. This is methadone's efficacy – it's endorphin replacement qualities. But this is only triggered upon a patient receiving an adequate dose. Some clinics in the US are seeing 90+% success rates, substantiated through monthly urine drug screens. The average dose in the US is between 80 and 120 milligrams, with some much higher depending on physical condition and metabolism of the patient. The doses in the UK are but a fraction of this. No wonder your system is a mess. You've yet to apply it properly.

Thank you for referring to the new collection I have edited which draws together some findings from a Department of Health (Policy Research Programme) research initiative on issues relating to drugs misuse treatment and care in England over the years paralleling the last ten year drugs strategy. May I comment on a few of the many interesting points you make in your blog.

It would be misleading to interpret the figure of £398 million allocated for the pooled treatment budget (in 2007/8) as being entirely spent on methadone prescribing as other costs are also included in this total.

Various chapters in my edited collection cast light on the question of the quality of services. It would be an exaggeration to argue that the quality of treatment services involving the prescription of methadone is universally low. Services may vary in quality but not all are poor and some are very good. A number of studies have highlighted differences in the quality of services – the 'agency effect' – but these show that some are better and some are worse. The challenge is to identify what makes for good quality in services.

It would also be misleading to imply that the issue of service quality has not been previously considered by policy makers. The NTA did place this question as a priority in their strategies once they had responded to the urgent need to expand the number of treatment slots, for example by embarking on an important project to improve the training of the workforce. (Initially the key issue was of poor and differential access to services as indicated by long waiting lists which were a serious matter of public disquiet in the late 1990s).

Research described in Responding to Drug Misuse (for example in chapters by Duncan Raistrick and colleagues and Tim Weaver and colleagues) shows that interventions available in the English drug treatment system include care-planned prescribing, community detoxification, low threshold prescribing, and Tier 2 interventions and treatment for both drugs and alcohol misuse. Services range widely in size and there is a wide range in the size of caseloads. The majority of services looked at in Tim Weaver's research had embraced case management principles and this approach was becoming embedded and refined over time. There were differences in the performance of agencies and differences in the reported experiences of service users. These do need to be understood and addressed. They may reflect such things as differences in the needs of service users as well as differences in management, funding, training, staff qualifications and experience. These need to be understood and dealt with intelligently rather than rushing to the conclusion that all services are of poor quality and should be closed down. More attention should be paid to improving the quality of therapy and improving training. And services have to adapt to new patterns of drug taking and to the needs of children and families – half of service users have children – as well as address issues which continue to be neglected such as polysubstance use and comorbidity. A wider range of services is needed – an expansion and adaptation not a wholescale destruction – including more support services to prevent relapse, maintain stability and overcome barriers to social reintegration.

Residential rehabilitation with stays of 12 months or so which were appropriate and effective for some drug misusers and promoted in the 1980s began to play a smaller part in the range of service provision after community care legislation came in, devolving the cost of such services to the local level. With the increased demand for services, consequent on a huge growth in problems relating to substance use from the 1980s onwards, commissioners looked to cheaper non-residential services to play a larger role in the array of services: both lengths of stay and the number of times an individual would be given a chance were reduced. This is not likely to change in today's days of austerity. And residential rehabilitation is not necessarily appropriate for all drug misusers,for example mothers with children.

Importantly clear improvements in outcome measures six months after treatment were observed in the research studies reported in the edited collection. This did not mean abstinence – the majority were still taking drugs illicit or prescribed. However patients in treatment did show health benefits and the majority of service users generally expressed some satisfaction with the services they received.

The main danger to avoid it seems to me is to conclude that there is one simple solution to a complex problem. In the early 1990s there was concern that the methadone budget was too high and a Conservative Health Minister aimed to save money and encourage abstinence by challenging the idea that methadone was a justifiable response to the needs of drug misusers. The enquiry which followed chaired by John Polkinghorne who was both a scientist and a Christian concluded that 'treatment works' and that methadone had a legitimate role to play, after a very thorough review of all the evidence available.

The ACMD report which encouraged a move to harm reduction in responding to the HIV/AIDS crisis of the 1980s was AIDS and Drug Misuse Part 2 1989 and was chaired by Professor DG Grahame Smith. It included among the members Professor Griffith Edwards, Jean Faugier, Les Kay, Professor Malcolm Lader, Ruth Runciman, Gerry Stimson, Anthony Thorley, David Turner and Tom Waller – and other leading figures in the field at that time. It concluded that at that time 'the spread of HIV is a greater danger to individual and public health than drug misuse'. In relation to prescribing it said 'prescribing can be a useful tool in helping to change the behaviour of some drug misusers either towards abstinence or towards intermediate goals such as reduction in injecting or sharing'. . .(the range of treatment goals would cover/ lead from the cessation of sharing of equipment, the move from injectable to oral drug use, decrease in drug misuse, and abstinence). They also concluded that 'no treatment package should continue indefinitely without review' . . .and 'only in the most exceptional cases would long term prescribing of injectable drugs be both necessary and effective in combating the spread of HIV'.

It is very interesting to read your blogs and your observations on policy on this side of the pond. Your calm voice is needed in what can sometimes appear to be a rather hysterical debate in UK at present. Thanks and I look forward to reading the next blog.

As you say, this has not been the case for decades. Usually rehab stays are 4-6 weeks, although a few can be longer or link to extended care. This means that a (usually) one-off stay in rehab at £500/£600/week equates financially to a year on methadone – less if we consider the capital costs and building maintenance needed for state prescribing premises.

Before the Community Care Act in 1992, I gather that 25% of people requesting to enter rehabs to get drug-free were enabled to do so. Now it is only 2% or so who can avail of it.

Totally agree with Susanne MacGregor et al's quote at end of her penultimate paragraph: "no treatment package should continue indefinitely without review… only in the most exceptional cases would long term prescribing of injectable drugs be both necessary and effective…"

Ongoing review, as recommended in ASAM's Patient Placement Criteria, is integral to good practice. Plus, of course, the capability to follow through on recommended actions identified in the review.

LAAM is no longer being used due to problems related to its alteration of the electrocardiogram and potential fatal cardiac dysrhythmias (which also can occur less significantly in methadone patients).

With respect to buprenorphine, a recent article states, "Although the prescription of methadone remains the dominant opioid treatment in England (83% of all prescriptions in 2005), buprenorphine prescribing increased from 1% in 1995 to 16% in 2005." (Ridge, G, et al, Journal of Substance Abuse Treatment, 37, 2009, 95-100.) In terms of efficacy, an article in press describes a comparison study of 227 methadone versus 134 buprenorphine in England and found that methadone led to greater treatment retention, but those retained on buprenorphine were more able to suppress illicit opiate use. Buprenorphine had merit also in increasing recruitment into treatment. (Pinto, H, et al, Journal of Substance Abuse Treatment, "The SUMMIT Trial: A field comparison of buprenorphine versus methadone maintenance treatment.")

Thanks Keith – what we need is a 21st century pharmacotherapy for people with opioid use disorder and the tools are mostly there: short-term stabilisation and withdrawal using bupremorphine; properly patient optimised maintenance (choice of methadone or suboxone) which winds up and delivers recovery momentum; and relapse prevention pharmacotherapy (eg oral or depot NTX). And all of this with behavioural interventions and supports. Now that's an aspirational list for sure and it might tax the skill and resource level of most partnerships but not pushing for a new technical model just opens things for the addiction as social problem ideologues to claim they have all the answers.

Thank you everyone for the above thoughtful comments and civilized debate about this contentious issue. The next 30 days will be of extraordinary interest with party conferences, green paper development and the spending review giving shape to what the new government will attempt to achieve in this and closely related policy areas — don't just "stay tuned", stay involved!

I think you are right that we 'need to look at outcomes', which was why I was dissapointed at your response to a question I put to you at the RAND conference in LA earlier this year regarding whether the US would look at the evidence (from Europe and elsewhere) for including heroin prescribing as alongside methadone as a treatment option. You were very dissmissive – I think stating that 'I don't think that would work here'. That response did not seem to reflect the committment to evaluating outcomes and the evidence base that you demonstrate above. Given the emerging evidence that (for a certain group of users, see here for example: http://bit.ly/cmVkfz ) heroin based treatment may deliver better outcomes than methadone, are the obstacles to exploring this option political or pragmatic?

Assessing the outcomes of methadone maintenance treatment is highly problematic, largely because it is flawed from the outset. Methadone is not a treatment. In my view methadone is only part of a treatment package (an important part) .

Those who see methadone as a treatment must assume that addiction is almost entirely about a physiological dependence to heroin. It is much more complex involving physical, psychological, social and legal components.

Methadone (or indeed heroin) prescribing can play an important role in providing the user with a clean, reliable and stable supply – relinquishing them of the burden of financing a habit often through criminal activities, removing the risk of dirty impure drugs and contact with the criminal networks.

Methadone is not treatment itself but for many who are not ready or able to become drug free it is an excellent base upon which to establish treatment. That treatment may involve: social skills development, coping strategies, alternative lifestyle habits, tackling low self esteem, counseling, improving diet, setting new goals, triggers, relapse, social integration, over coming stigma and learning to mix outside of a drug centred lifestyle, education, employment etc.

Excellent methadone maintenance prescribing policy and practice will struggle to provide successful outcomes if the therapeutic [treatment] input is seriously lacking, so we cannot judge in isolation.

As a service user of 20 years or more I am astonished how the debate over about Methadone or drug treatment in general appears to occur in such a rarefied atmosphere.

Getting lots of people into treatment quickly and keeping them there has always been the overriding goal of drug treatment. The goal was set as a response to the perceived threat of HIV/AIDS and further by crime reduction agendas. In that sense it has been split between reducing the impact on "the rest of society" and the substance misuser.

It is clear where the priority lays, treatment which precipitates a recovered position for the individual is desirable and it has been a bonus if someone moves on as a result of treatment, but not essential to its outcome measures or its existence.

It is important to remember that without the bums on seats we would not be having a debate about what to do with them. I agree whole heartedly with David Best's “A few hours of counseling" critique. but any critique of the quality of service provision, however accurate and well founded, must be considered within the original remit of that service provision and not as a rational for doing things differently, although he is right on many of the issues its not because everything is of poor quality, its because you get what you pay for. There wasn't the money then to get everyone a counselor or put them through rehab never mind now.

A drift into long term methadone prescribing is inevitable under the current system, reducing service users ability to recover particularly in the areas that Julian Buchanan mentions. This begins to question the whole management of the crisis, that’s what treatment does; it manages a crisis for society with service user needs running secondary to this. The effect of this is that it’s safer for everyone but this reduces the motivation to change, throw in an entitlement to increased benefits with no requirement to work and some will view this as a incentive to remain on methadone.

If we consider that for some there may a rational for not treating, after all we don’t balk at refusing surgery for smokers until they have given up. Are we prepared to tolerate what this may mean, is it more or less ethical than the methadone ghetto with the potential for trans generational use?

I feel I need to be clear here I am not anti methadone or anti treatment. I would like to see a debate which incorporates all the social parameters that are clearly apparent anything less is just playing to the gallery or worst the vested interest.

Asking service users,( Which I have done both locally and nationally ) about what they want is first port of call I believe. So far, a majority of those I ask want to be free of addiction/dependance when they have stablised,and just want the safety of a script when using, to avoid the chaotic lifestyle and risks.Most need to ''Catch their breathe '' and think about where they are.

To precis a lot of responses,a picture emerges of (maybe) a year to get stable and begin keyworking etc.,and recovery to be addressed with reduction scripts in the second year for those that want it. Anyone who wants to remain scripted for longer than this should pay for their own script on a long term basis.

Too much time and money are being wasted currently,with very little help for alcohol and stimulant addiction,neither of which have a similar cornucopiua of chemical alternatives as for opiate addiction.

Mark Kleiman is right: the trial of time limits on methadone has been done over and over and over and found wanting. Never once have we developed a 12-step paradise of abstinence by cutting people off methadone. Not in the US, not in the UK, nowhere. The results are universally deadly and harmful.

When you close methadone clinics, you get increased overdose death and increased crime; when you open them, you get the reverse.

Methadone gets a bad name because it "self selects" exactly the opposite way than 12-step programs do: in 12 step programs, the recovering, happy, healthy people are visible because they come to meetings while the other folks drop out. In methadone, the people still using on top who are not doing well are the ones that hang round the clinic and talk to the media. So, with methadone, we overwhelmingly see the "failures"– while with 12-step abstinence, the failures are hard to find because they don't come to meetings and don't speak to the media. With methadone, the successes don't speak to the media because the stigma is that they are "not in recovery" and therefore, there's nothing to distinguish them from the failures. (Incidentally, the fact that the "failures" stay in the medical system is a feature not a bug of methadone: it allows more chances to reach them and help).

Yes, it's true that with no methadone maintenance, some people who would otherwise have become drugfree stay on methadone. But it's also true that with no methadone maintenance, some people who would have otherwise survived die. Given that dead addicts can't recover, we've got to pick long term maintenance and give people *choices* about coming off. Not force them, not push them, but attract those who want to try into doing it– and then let those who do better on maintenance do better and don't shame them.

Maia, I totally agree. In my opinion choice is paramount. So is methadone maintenance. In the word of one of my tutors, all we can do is stop people dying until THEY DECIDE to attempt/maintain abstinence.

Also, what you have said about the press makes sense. With most methadone clinics in city centres, those who use them are visible. Further, if they have travelled five miles and have to see their keyworker five hours later it is not worth them going home because they would have to leave as soon as they got there. So, we end up with a scenario where people, who are addicted to Class A drugs, are left hanging around city centres where drugs are easily available.

I believe that there is a case for more local initiatives along the lines of local pharmacy prescribing. Yes to methadone and yes to 12 step programmes. Even more though, YES TO CHOICE.